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FarmaSafe@:design, development and deployment
of a Hospital-wide CPOE system
Ing. Antonio FumagalliOspedali Riuniti di Bergamo - Italy
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Manama - Bahrain, May 6th 2009
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• Bergamo Hospital contest
• FS@: project and objectives
• FS@: workflow, clinical and patient benefits
• FS@: “hospital virtual drug”
• FS@: daily use and traceability
• FS@: “up to date” key informations
• FS@: technical elements ad system architecture
• FS@: training, roll-out and users assistance
• FS@: experience, evolution and conclusion
Realization 1927-1930, pavilions building Beds: 906 Operating rooms: 32 Intensive Care units: 6 Personnel > 4000 Bergamo’s County residents > 1.000.000
Ordinary 2008 activities: Inpatient: 38.396 Day Hospital: 14.984 Surgery: 34.354 Outpatient: 3.665.534 Hospitalization day (avg): 7,56 days Bed occupation ratio: 83,94% Transplant: 168 Bone marrow transplant: 102 Pharmaceutics expense > 33 M€
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31,39
33,54
7,718,95
11,5912,70
0
5
10
15
20
25
30
35
40
2005 2006
Million €
All Drugs Antiblastic Antiviral
Organizational and functional Analysis: Sept.-Dec. 2004
Start up of (2 clinical units + pharmacy):
Go-live (2 clinical units + pharmacy): November 2006
Safety and Risk analysis engineering test: November 2006
Progressive :
Official release 1.0: June 2007
Release 1.9: December 2008
:
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from , through , to arrive ataction
Organizational process improvement/optimisation among nurse, clinician and pharmacist
(i.e. therapy error reduction), assistance time dedicatedto the patient
with plenty of report
Paperless operations
User clearly identified for clinical/legal matter
System available everywhere,
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Prescription(physician)
“everywhere”
Preparation(pharmacist)“laboratory”
Preparation(nurse)“ward”
Formulation(pharmacist)“pharmacy”
“protocol”, “compound”, “ward handbook”
“Galenical”“Nutrition”
“Antiblastic”“Vaccines”
“assembly”
“ancillary”“infusion”
“antibiotic”
“assembly”
“medication cart” “plate”
“ready”
Dispense(nurse)“ward”
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• Protocol schema and compound clearly defined, based ontherapeutic/pharmacological validation from physician/pharmacist
• Dose calculated in mg based on anthropometric parameter• Compound, drugs handbook defined for single clinical specialty
• Clear and detailed e-prescription • Univocal preparation label by patient/drug
• Patient and drug unambigous identification• Dose, dispense route and time defined
• Patient therapy usable, always up to date in real timeto users everywhere they are working
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“bedside”
“laboratory”“ward”
“bedside”
“ancillary”“infusion”
“Galenical”“Nutrition”
“Antiblastic”
“assembly” “assembly”
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Drug coding extended to “7th ATC level”: ATC + pharmaceutical shape + dose
ATC Level ATC Code ATC Group ATC Description
1° A Anatomic Alimentary tract and metabolism
2° 02 Therapeutic Drugs for acid related disorders
3° B Therapeutic Drugs for peptic ulcer
4° C Therapeutic Proton pump inhibitors
5° 01 Chemical Omeprazole
6°Pharmaceutical
ShapeOral capsule
7° Dose 20 mg
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ActivePrinciple
CommercialName
‘virtualhospital drug’
ANTRA 20*14CPS RIL.MOD. BLIS
MEPRAL 20*14 CPS 20 MG BLISTER
OMEPRAZEN 20*14CPS 20MG BLIS
LOSEC*14 CPS RIL.MOD.20MG BL
OMEPRAZOLE
‘OMEPRAZOLE 20 mg’
Available Commercial
Name
MEPRAL 20*14 CPS 20 MG BLIST
Prescription(needed)
Dispense(available drug)
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Protocols and compounds are always valid due to independence from
commercial drug name
With dose and pharmaceutical shape is possible to convert pieces/mg
and viceversa for a complete dispense safety
During prescription the physician does not care about the commercial
specialty available to dispense
Therapy is always valid: physician does not need to change anything
due to commercial product logistic modification (new brand in Hospital
for example)
To get patient data + read barcode from label on prepared drug
Barcode is
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“every chemoterapy drug owns a progressive unique numberfor the dispense”
Patient selection by drug barcode label
Dispense sequence check
Drug (right) check when dispense is readyto start using patient barcode
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Clinical event operated: more than 47.000 Labeled pharmacologic preparation : more than 850.000 Chemotherapy protocol schema available to prescribe: 579 Pharmacologic compound ready to prescribe: around 1000 Prescribed chemotherapy schema: more than 25.000 Recorded dispense : more than 2.700.000
today Remaining ward: 10 to roll-up by 2009 end Users: 414 physician, 859 nurse, 7 pharmacist, 4 IT
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Quarter 30/06/2006 3° 4° 31/03/2007 2° 3° 4° 31/03/2008 2° 3° 4° 31/03/2009
Patient Nurse Physician Dispense
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Ospedali Riuniti di Bergamo (03/2009)
Broker and integration engine
RegionalExtranet
Middleware
A.Fumagalli
Order Entry
CUP
OutpatientAgenda
ADT
DischargeLetter
Master Patient Index
PatientDemographics
Clinical Data Repository
ClinicalData
CDA2
ROL
XML/CDA2
SISS
REL
XML/CDA2
EPR-EHR
LAB Information System
LABData
Document Repository
Signed PDFdocument
LABReport
RIS/PACS
Images
Blood Information System
BloodUnit
FarmaSafe@ (CPOE)
Therapy
LABOrder
Blood Transfusion System
BloodUnit
Order
Operating Rooms
Surgeryrecord
Admission
Emergency
Emergencyreport
Ospedali Riuniti di Bergamo (03/2009)
A.Fumagalli
Database Server
Application Server
Application Server
Load Balancer
Serv
er
Farm
Ward
A
AccessPoint Wireless
AccessPoint Wireless
Ward
B
AccessPoint Wireless
AccessPoint Wireless
Ethernet Lan
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San
ità e
Mo
bilit
à:
l’esp
eri
en
za d
egli O
sped
ali R
iun
iti
di B
erg
am
o n
ei p
rocess
i in
form
ati
zzati
di
Rep
art
o
Exp
oS
anit
à2
00
8 –
Oss
erva
tori
o IC
T &
CIO
in S
anit
à, B
olo
gn
a 30
Mag
gio
20
08 ‘access point’ installation to
on whole ward area (60+ equipment today)
Equipment configuration to guarantee(e.g. tablet, computer on cart)
Use of standard “802.11g”
Large use of wireless device for complete nurse/clinicians mobility( )
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Functionality testing For single software function (e.g. patient search)
For process (e.g. prescription/dispense of continuous infusion therapy)
For state/transition of application element (e.g. drug state change inside
a chemoterapy protocol: prescribed, running, suspended, ended, …)
Safety testing Critical event identification (wrong dose, wrong patient, …)
Model to simulate critical events (improper behavior of software,
ambiguous data, ... )
Utilization of test case to check a possible critical event generation
Executed tests: around 2.700
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Process test: prescription/dispense
of continuous infusion therapy
Safety test:
wrong dose critical event
San
ità e
Mo
bilit
à:
l’esp
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egli O
sped
ali R
iun
iti
di B
erg
am
o n
ei p
rocess
i in
form
ati
zzati
di
Rep
art
o
Exp
oS
anit
à2
00
8 –
Oss
erva
tori
o IC
T &
CIO
in S
anit
à, B
olo
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a 30
Mag
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08
Complete training to physician and nurse: 8 classroom hour per user
(IT, pharmacist and nurse): presence for 8 weeks directly in ward
One PC on every therapy cart, one PC in every Day Hospital room
Phone Help-desk and user documentation available
IT assistance 24x7
“UNINTENDED TRANSFORMATIONS OF CLINICAL RELATIONS WITH A COMPUTERIZED PHYSICIAN ORDER ENTRY SYSTEM”
(WENTZER, ET AL., INTERNATIONAL JOURNAL OF MEDICAL INFORMATICS, 2007)
Actors collaboration complete paperless workflow
Logistic and pharmaceutical centered “virtual drug” concept
System availability robust IT architecture, paper backup available
Clinical Specialty different functionality
Social and technological evolution iterative revision process with Project Team
Tool usability continuous analysis and improvement
Care continuity e-prescription to keep on therapy after hospitalization
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analysis already completed, ready to start field experimentation
recording and use during prescription with international standard HL7 e WHO ATC
during prescription using an online and up-to-date database : alert to the physician
Complete process traceability with
Integration with Hospital EPR (some integration already active with departmental EPR)
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Ing. Antonio FumagalliOspedali Riuniti di Bergamo – [email protected]
